Provider Demographics
NPI:1730149196
Name:GROESCH, DAVID (AUD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:GROESCH
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 WESTGATE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-7066
Mailing Address - Country:US
Mailing Address - Phone:217-726-6101
Mailing Address - Fax:217-546-4659
Practice Address - Street 1:4000 WESTGATE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-7066
Practice Address - Country:US
Practice Address - Phone:217-726-6101
Practice Address - Fax:217-546-4659
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147-000273231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7313366OtherAETNA INS. PROV. NO.
IL8422416OtherBLUE CROSS BLUE SHIELD
IL988490Medicare ID - Type Unspecified
IL7313366OtherAETNA INS. PROV. NO.